What is the best approach for intubating a patient with massive haemoptysis, likely due to underlying respiratory or cardiovascular disease, and critically low oxygen saturation levels?

Intubation Approach for Massive Haemoptysis

Use a large-bore single-lumen endotracheal tube (≥8.0mm) rather than a double-lumen tube, as this allows effective bronchoscopic suctioning to clear blood clots—the primary cause of death in massive haemoptysis is asphyxiation from airway obstruction, not exsanguination. 1, 2

Immediate Airway Management Priorities

Pre-intubation Positioning

• Position the patient with the bleeding lung in the dependent position if the bleeding side is known, to protect the non-bleeding lung from blood aspiration 3
• Maintain head-up tilt during intubation to prevent aspiration and optimize venous drainage 4

Oxygenation Strategy

• Administer high-flow oxygen (FiO₂ 100%) immediately 1, 4
• Do not delay intubation waiting for oxygen saturation to normalize—in massive haemoptysis with copious secretions and airway blood, achieving high SpO₂ before intubation may be impossible, and delaying intubation increases mortality risk 1
• Consider high-flow nasal oxygen for pre-oxygenation in non-severely hypoxaemic patients, though its benefit is limited in massive bleeding 1

Intubation Technique

• Perform rapid sequence intubation treating the patient as having a "full stomach" due to blood in the airway 1
• Use fentanyl 3-5 µg/kg or remifentanil (target ≥3 ng/mL) for induction; consider ketamine 1-2 mg/kg if hemodynamically unstable 4
• Apply Sellick maneuver during intubation 1

Endotracheal Tube Selection

Single-Lumen Tube (Preferred)

A single-lumen cuffed endotracheal tube with the largest possible diameter (≥8.0mm) is superior to double-lumen tubes for the following reasons 1:

• Permits passage of therapeutic bronchoscope for visualization and suctioning
• Allows rapid removal of large obstructing blood clots
• Easier and faster to place correctly
• More reliable positioning in emergency situations

Selective Mainstem Intubation

• If the bleeding side is known, advance the single-lumen tube into the non-bleeding mainstem bronchus to isolate and protect the healthy lung 1, 3
• This technique is preferable to double-lumen tubes in the emergency setting 1

When Double-Lumen Tubes Fail

Double-lumen endotracheal tubes have significant limitations in massive haemoptysis 1:

• Smaller internal diameter limits suctioning capability
• Difficult to position correctly during active bleeding
• Cannot accommodate therapeutic bronchoscope through each lumen
• Higher failure rate in emergency placement

Post-Intubation Management

Ventilation Strategy

• Apply PEEP of at least 5 cmH₂O after intubation 1
• Consider post-intubation recruitment maneuver (40 cmH₂O CPAP for ≥30 seconds) in hypoxaemic patients 1
• Use pressure-controlled mandatory ventilation with 100% oxygen 1
• Validate end-tidal CO₂ with arterial blood gas 4

Immediate Bronchoscopy

• Perform urgent flexible bronchoscopy during active bleeding to lateralize the bleeding side, localize the specific site, and identify the cause 5, 3
• Bronchoscopy localizes bleeding in 90% of cases versus 64% with chest X-ray alone 5
• Use bronchoscopic suctioning aggressively to clear blood clots 1

Endobronchial Hemorrhage Control

If bleeding continues after intubation 1:

• Wedge bronchoscope tip tightly into bleeding bronchus for tamponade
• Instill iced saline to induce vasoconstriction
• Apply bronchial blockade balloons (may need to remain 24-48 hours)
• Consider topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% immediate success rate) 1

Vascular Access and Resuscitation

Establish Large-Bore Access

• Place 8-Fr central venous access or largest possible peripheral IV 1, 4
• Consider intraosseous access if IV access fails 1

Baseline Laboratory Studies

Draw immediately 1, 4:

• Complete blood count
• PT, aPTT, Clauss fibrinogen (not derived fibrinogen)
• Cross-match
• Consider near-patient testing (TEG/ROTEM) if available

Hemodynamic Management

• Target mean arterial pressure >65-70 mmHg to maintain cerebral perfusion 4
• Avoid aggressive hypotensive resuscitation—adequate perfusion is essential 4
• Use judicious vasopressors only if hypotension persists despite volume resuscitation 4

Definitive Hemorrhage Control

Bronchial Artery Embolization (First-Line)

• Embolization is superior to emergency surgery for acute massive haemoptysis control 5, 2, 6
• Significantly better than medical treatment alone for immediate cessation (p<0.05) 6
• Success rate of 51% in controlling bleeding 5
• Perform urgently once airway is secured 1, 7

Emergency Surgery (Reserved for Failures)

• Only 13% of patients require emergency surgery 5
• Reserved for cases where embolization fails or is not feasible 5, 3
• Associated with extremely high mortality in hemodynamically unstable patients 7
• Mortality rate in lung cancer patients with massive haemoptysis: 59-100% 1

Common Pitfalls to Avoid

• Do not use double-lumen tubes as first choice—they compromise suctioning ability and are difficult to place during active bleeding 1
• Do not delay intubation waiting for perfect oxygenation—blood clot airway obstruction kills faster than hypoxemia 1, 2
• Do not use small-diameter endotracheal tubes—inadequate diameter prevents effective clot removal 1
• Do not proceed to emergency surgery before attempting embolization—nonsurgical control is superior in acute situations 2
• Avoid using derived fibrinogen values; insist on Clauss fibrinogen for accurate coagulation assessment 4